Medical billing has reached “timeshare” status

Discussion in 'The Okie Corral' started by catman71, Jan 18, 2020.

  1. pugman

    pugman

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    Buckle up.

    I work for the largest health insurance company in the world. While you may not believe this...the insurance company is always on your side. They may deny services but there is always a reason. Medical necessity (and many of these are over turned on a record review), coding issues, true fraud, etc.

    The ways a provider can be paid is mind boggling. POC (percent of charge), per diem, case rates, carve outs, outpatient fee schedules, DRGs, stop loss clauses, etc. etc.

    There is massive amounts of abuse in the provider space. Case in point: me.

    I went to the ER in August for a severe GI bleed. A Ct scan, a colonoscopy and 33 hours of observation left me with patient responsibility of nearly $5,000. My wife and I are blessed with good health so much of this is deductible. I expected a bill.

    Unfortunately for the provider I'm a senior auditor. They are paid at a percent of charge and billed nearly $5,000 for hydration therapy...for those not in the field those are IV bags. Over the 33 hours they hung 5. I was charged $5K for about $20 of salt water.

    On the detail bill I requested there is an upadjust line item which reads "Contractual allowence adjustment" of $5,273.58. No one at the provider can tell me what this is?

    I just attended a town hall meeting for my employer. I forget which indepedent watch dog group just dropped a report but its estimated there is $1 trillion dollars of waste and abuse in the medical industry.

    And to be fair...this abuse goes both ways. I'm working a project now looking at members who excessively use preventive visits. No, we are not talking people seeing a doctor a few times a year. We are talking those who have 20 or more preventative visits annually.

    I feel sorry for people who have catastrophic medical claims, see huge bills land at their feet, and have no way of understanding them.
     
    Last edited: Jan 18, 2020
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  2. Otto Pistol

    Otto Pistol

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    Sometimes, the doctor sees (with a dilated retinal exam) changes in the retina (hemorrhages, exudates, engorged blood vessels) indicating high blood pressure or diabetic retinopathy long before symptoms of those conditions manifest themselves.

    Children should have a dilated retinal exam to establish a baseline of healthy retinas. Retinoblastoma is a rare child cancer (1 in 18,000- 90,000 live births) but if your child had it, you would want to know sooner rather than later. A problem is sometimes noted in snapshots taken in dim rooms, instead of “red eye” it is “white eye” (a white pupil).

    if you don’t have high blood pressure or diabetes, get a dilated retinal exam at least every few years, more frequently as you become elderly and are at risk for macular degeneration.

    If you have a sudden change in vision (blurred vision, distorted vision, blind spot, a veil or shadow interfering with vision) see an eye doctor IMMEDIATELY. It might be a macular hemorrhage, a subretinal neovascular net, uncontrolled glaucoma, or a retinal detachment. The eye you save may be your own.

    End of PSA.
     
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  3. Ramjet38

    Ramjet38 Mentally Frozen

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    Said the dumb man.
     
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  4. pittpa

    pittpa What did I come in here for?

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    As he picked up his hammer and saw


    Sent from my iPhone using Tapatalk
     
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  5. podwich

    podwich

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    You're right. I don't believe it.
     
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  6. Intolerant

    Intolerant

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    ALL insurance companies are, are a scam, whether its healthcare or car insurance, SCAMMERS!
    Whenever the word insurance is brought up, they are the winners, you are the losers.

    Until we beat the middleman out of the healthcare system, it will never be fixed.
    One thing that helps, eat healthy. You`ll have less doctor visits. Less is more.

    Another thing too, dont run your damn kids to the doctor every time they have a god damn runny nose!
     
    Last edited: Jan 19, 2020
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  7. railfancwb

    railfancwb

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    Recently I have received two statements saying that I owe X. Both from anesthesiologists. Both showed a total amount, the agreed insurance markdown, and the amount insurance “unpaid”.

    One wanted me to pay the total including the agreed insurance markdown. The other only wanted me to pay the amount insurance took back. Didn’t pay anything to either, and complained to both. Both were supposedly coding errors.
     
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  8. pugman

    pugman

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    Can you give me an example? Seriously.

    I've had people with ASO insurance tell me we suck. The problem is their employer sets the rules we play by. We just pay the claim.

    Insurance isn't a scam...its what its intended to be 98% pay for the other 2%.

    If you knew what physicians and facilities billed and are paid for services and the scams I see daily you would understand.
     
  9. kiole

    kiole

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    Health insurance companies are very short sited. My family member had ureter cancer that spread to a kidney. The kidney and ureter were removed. Almost 100% chance of bladder cancer within their life time. Typically relatively close to first diagnosis.

    The insurance company refuses to provide a yearly PET scan as requested by his doctors. They’ll likely now catch the cancer when it comes back at a much later stage. This will increase the cost to treat 1000% and could require bladder removal or possible removal of kidney and a kidney replacement or dialysis.

    When insurance companies dictate care we end up with later diagnosis and more expensive care.
     
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